Senior Quality Improvement Professional; HEDIS

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The Senior Quality Improvement Professional will focus organizational efforts on improving Kentucky Medicaid clinical quality performance measures to achieve optimal performance and quality for the Humana Healthy Horizons in Kentucky Medicaid Plan. Plans, performs, and implements cross-functional initiatives, analyzes and measures the effectiveness of existing business processes, and develops sustainable, repeatable, and quantifiable quality and process improvements. Works closely with the Quality Improvement and market leaders to promote an organization-wide culture of quality improvement.

The Senior Quality Improvement Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Quality Improvement Professional uses data to develop and lead quality improvement projects and monitors performance metrics for KY Medicaid.

• Updates, manages, and complies the QI requirement documentation (QI Program Description, QI Work Plans, and QI Evaluation)

• Develops, implements, and evaluates activities of state required Performance Improvement Projects (PIPs) in collaboration with internal and external partners

• Facilitates/participates in quality committees and quality improvement related meetings and discussion with internal and external partners

• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

• Develops strategy to improve Performance Measures as identified by the state.

• Assesses drivers for low performing measures

• Develops interventions to improve Performance Measure rates

• Assesses need for member and provider collateral information (i.e. HEDIS tip sheets, other support pieces – i.e. provider web based training) and develops collateral documentation needed

• Works with analyst to develop Performance Measure view for performance measures and identify those practices who potentially need assistance with performance measures (i.e. HEDIS measure analysis)

• Leads and participates in QI activities designed to improve performance measures

• Collaborates with member and provider facing teams to drive QI activities

• Subject Matter Expert for all member and provider quality and performance measures content for documents like the Enrollee Newsletter, Provider Manual, and quality documents

• Strong relationship building skills

• Excellent written and oral communication skills

• Ability to work independently under general instructions, must be self-directed and motivated.

• Active, unrestricted Registered Nurse (RN) license.

• 3+ years' experience working with Medicaid and/or Medicare programs and regulations.

• 3+ years' experience collaborating with state agencies or the Centers for Medicare & Medicaid Services (CMS).

• 3+ year experience leading or supporting Quality Improvement and Performance Improvement projects .

• 3+ years of direct experience and knowledge of healthcare quality measurement programs , including HEDIS, Star Ratings, and related performance metrics .

• 1+ year of experience with HEDIS supplemental and/or hybrid data abstraction ,
  medical record review , and quality audit activities .

• Proficiency with Microsoft Office applications, including Word, Excel, and Power Point .

• Strong analytical and problem-solving skills with the ability to interpret data and identify trends .

• Experience working with Kentucky Medicaid programs and regulations.

• Knowledge of Humana organizational policies, procedures, and operational systems.

• Schedule/Time Zone: Monday through Friday,…